The SAGES Manual of Colorectal Surgery

This book provides essential didactic content for the SAGES University Masters Program Colorectal Surgery Curriculum. Surgeons seeking to complete the competency, proficiency, or mastery curriculum of the MASTERS Colorectal Pathway for a particular anchoring colorectal procedure will find relevant educational content in this SAGES Manual. Written by experts in the field, each chapter provides detailed guidance on preoperative and peri-procedural considerations for right and left elective and emergency colorectal resections, for both benign and malignant pathologies. Technical pearls and strategies to manage pitfalls and complications are also extensively reviewed along with detailed guidance for both laparoscopic and robotic procedures.

The SAGES Manual of Colorectal Surgery provides a wealth of practical guidance to surgeons along their journey to progress from competency to mastery in various minimally invasive approaches to colorectal surgery.

• Language: English
• Publisher: Springer
• Release date: Oct 17, 2019
• ISBN: 9783030248123

Book preview

Part IMasters Program Anchoring Procedures

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

P. Sylla et al. (eds.)The SAGES Manual of Colorectal Surgeryhttps://doi.org/10.1007/978-3-030-24812-3_1

1. SAGES University MASTERS Program: Colorectal Pathway

Daniel B. Jones¹  , Linda Schultz²   and Brian P. Jacob³  

(1)

Beth Israel Deaconess Medical Center; Harvard University Medical School, Boston, MA, USA

(2)

Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA, USA

(3)

Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA

Daniel B. Jones (Corresponding author)

Email: [e-mail]

Linda Schultz

Email: [e-mail]

Brian P. Jacob

Keywords

ColonCompetencyProficiencyMasteryCoaching

Adapted with permission of Springer Nature from Jones, DB, Stefanidis D, Korndorffer JR, Dimick JB, Jacob BP, Schultz L, Scott DJ, SAGES University Masters Program: a structured curriculum for deliberate, lifelong learning. Surg Endoscopy, 2017;31(8):3061–71.

Introduction

The MASTERS Program organizes educational materials along clinical pathways into discrete blocks of content which will be accessible to surgeons at the SAGES annual meeting or logging into the online SAGES University (Fig. 1.1) [1]. The SAGES MASTERS Program currently includes 8 pathways: acute care , biliary, bariatrics, colorectal, foregut, hernia, flexible endoscopy, and robotic surgery (Fig. 1.2). Each pathway is divided into three levels of targeted performance: competency, proficiency, and mastery (Fig. 1.3). The levels originate from the Dreyfus model of skill acquisition [2], which has five stages: novice, advanced beginner, competency, proficiency, and expertise. The SAGES MASTERS Program is based on the three most advanced stages of skill acquisition: competency, proficiency, and expertise. Competency is defined as what a graduating general surgery chief resident or MIS fellow should be able to achieve; proficiency is what a surgeon approximately 3 years out from training should be able to accomplish; and mastery is what a more experienced surgeon should be able to accomplish after several years in practice. Mastery is applicable to SAGES surgeons seeking in-depth knowledge in a pathway, including the following: areas of controversy, outcomes, best practice, and ability to mentor colleagues. Over time, with the utilization of coaching and participation in SAGES courses, this level should be obtainable by the majority of SAGES members. This edition of the SAGES Manual of Colorectal Surgery aligns with the current version of the new SAGES University MASTERS Program Colorectal Surgery Pathway (Table 1.1).

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Fig. 1.1

MASTERS Program logo

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Fig. 1.2

MASTERS Program clinical pathways

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Fig. 1.3

MASTERS Program progression

Table 1.1

MASTERS Program colorectal curriculum outline

Colorectal Surgery Curriculum

The key elements of the Colorectal Surgery curriculum include core lectures for the pathway, which provide 45-minute general overview including basic anatomy, physiology, diagnostic work-up, and surgical management. As of 2018, all lecture contents of the annual SAGES meetings are labeled as follows: basic (100), intermediate (200), and advanced (300). This allows attendees to choose lectures that best fit their educational needs. Coding the content additionally facilitates online retrieval of specific educational material, with varying degrees of surgical complexity, ranging from introductory to revisional surgery .

SAGES identified the need to develop targeted complex content for its mastery level curriculum. The idea was that these 25-minute lectures would be focused on specific topics. It assumes that the attendee already has a good understanding of diseases and management from attending/watching competency and proficiency level lectures. Ideally, in order to supplement a chosen topic, the mastery lectures would also identify key prerequisite articles from Surgical Endoscopy and other journals, in addition to SAGES University videos. Many of these lectures will be forthcoming at future SAGES annual meetings.

The MASTERS Program has a self-assessment, multiple choice exam for each module to guide learner progression throughout the curriculum. Questions are submitted by core lecture speakers and SAGES annual meeting faculty. The goal of the questions is to use assessment for learning, with the assessment being criterion-referenced with the percent correct set at 80%. Learners will be able to review incorrect answers, review educational content, and retake the examination until a passing score is obtained.

In addition to this new edition of the SAGES Colorectal Surgery Manual, the MASTERS Program Colorectal Surgery curriculum taps much of the SAGES existing educational products including FLS®, FES™, FUSE™, SMART™, Top 21 videos, and Pearls (Fig. 1.4a–d). The Curriculum Task Force has placed the aforementioned modules along a continuum of the curriculum pathway. For example, FLS, in general, occurs during the Competency Curriculum, whereas the Fundamental Use of Surgical Energy (FUSE) is usually required during the Proficiency Curriculum. The Fundamentals of Laparoscopic Surgery (FLS) is a multiple choice exam and a skills assessment conducted on a video box trainer. Tasks include peg transfer, cutting, intracorporeal and extracorporeal suturing, and knot tying. Since 2010, FLS has been required of all the US general surgery residents seeking to sit for the American Board of Surgery qualifying examinations. The Fundamentals of Endoscopic Surgery (FES) assesses endoscopic knowledge and technical skills in a simulator. FUSE teaches about the safe use of energy devices in the operating room and is available at FUSE.​didactic.​org. After, learners complete the self-paced modules, and they may take the certifying examination.

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Fig. 1.4

(a–d) SAGES educational content : (a) FLS®; (b) FES™; (c) FUSE™; (d) SMART™. (Trademarks by SAGES)

The SAGES Surgical Multimodal Accelerated Recovery Trajectory (SMART) Initiative combines minimally invasive surgical techniques with enhanced recovery pathways (ERPs) for perioperative care, with the goal of improving outcomes and patient satisfaction. Educational materials include a website with best practices, sample pathways, patient literature, and other resources such as videos, FAQs, and an implementation timeline. The materials assist surgeons and their surgical team with implementation of an ERP.

Top 21 videos are edited videos of the most commonly performed MIS operations and basic endoscopy. Cases are straightforward with quality video and clear anatomy.

Pearls are step-by-step video clips of ten operations. The authors show different variations for each step. The learner should have a fundamental understanding of the operation.

SAGES Guidelines provide evidence-based recommendations for surgeons and are developed by the SAGES Guidelines Committee following the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine standards (formerly the Institute of Medicine) for guideline development [3]. Each clinical practice guideline has been systematically researched, reviewed, and revised by the SAGES Guidelines Committee and an appropriate multidisciplinary team. The strength of the provided recommendations is determined based on the quality of the available literature using the GRADE methodology [4]. SAGES Guidelines cover a wide range of topics relevant to the practice of SAGES surgeon members and are updated on a regular basis. Since the developed guidelines provide an appraisal of the available literature, their inclusion in the MASTERS Program was deemed necessary by the group.

The Curriculum Task Force identified the need to select required readings for the MASTERS Program based on key articles for the various curriculum procedures. Summaries of each of these articles follow the American College of Surgeons (ACS) Selected Readings format.

Facebook™ Groups

While there are many great platforms available to permit online collaboration by user-generated content, Facebook™ offers a unique, highly developed mobile platform that is ideal for global professional collaboration and daily continuing surgical education (Fig. 1.5a, b). These Facebook groups allow for video assessment, feedback, and coaching as a tool to improve practice.

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Fig. 1.5

(a, b) Colorectal Surgery Facebook™ Group . (Trademark by Facebook)

Based on the anchoring procedures determined via group consensus (Table 1.2), participants in the MASTERS Program will submit video clips on closed Facebook groups, with other participants and/or SAGES members providing qualitative feedback. For example, for the colorectal competency pathway , surgeons would submit the critical steps during a laparoscopic right colectomy such as identification of the duodenum or mobilization of the ileocolic vessels. Using crowdsourcing, other surgeons would comment and provide feedback.

Table 1.2

Colorectal surgery anchoring procedures by pathway

Eight uniquely vetted membership-only closed Facebook groups were created for the MASTERS Program, including a group for bariatrics, hernia, colorectal, biliary, acute care, flexible endoscopy, robotics, and foregut. The Colorectal Surgery Facebook group is independent of the other groups and will be populated only by physicians, mostly surgeons or surgeons in training interested in colorectal surgery. The group provides an international platform for surgeons and healthcare providers interested in optimizing outcomes in a surgical specialty to collaborate, share, discuss, and post photos, videos, and anything related to a chosen specialty. By embracing social media as a collaborative forum, we can more effectively and transparently obtain immediate global feedback that can potentially improve patient outcomes, as well as the quality of care we provide, all while transforming the way a society’s members interact.

For the first two levels of the MASTERS Colorectal Surgery Program, Competency, and Proficiency, participants will be required to post videos of the anchoring procedures and will receive qualitative feedback from other participants. However, for the mastery level, participants will submit unedited videos to be evaluated by an expert panel. A standardized video assessment tool, depending on the specific procedure, will be used. A benchmark will also be utilized to determine when the participant has achieved the mastery level for that procedure.

Once the participant has achieved mastery level, they will participate as a coach by providing feedback to participants in the first two levels. MASTERS Program participants will therefore need to learn the fundamental principles of surgical coaching. The key activities of coaching include goal setting, active listening, powerful inquiry, and constructive feedback [5, 6]. Importantly, peer coaching is much different than traditional education, where there is an expert and a learner. Peer coaching is a co-learning model where the coach is facilitating the development of the coachee by using inquiry (i.e., open-ended questions) in a noncompetitive manner.

Surgical coaching skills are a crucial part of the MASTERS curriculum. At the 2017 SAGES Annual Meeting, a postgraduate course on coaching skills was developed and video recorded. The goal is to develop a coaching culture within the SAGES MASTERS Program, wherein both participants and coaches are committed to lifelong learning and development.

The need for a more structured approach to the education of practicing surgeons as accomplished by the SAGES MASTERS Program is well recognized [7]. Since performance feedback usually stops after training completion and current approaches to MOC are suboptimal, the need for peer coaching has recently received increased attention in surgery [5, 6]. SAGES has recognized this need, and its MASTERS Program embraces social media for surgical education to help provide a free, mobile, and easy to use platform to surgeons globally. Access to the MASTERS Program groups enables surgeons at all levels to partake in the MASTERS Program curriculum and obtain feedback from peers, mentors, and experts. By creating surgeon-only private groups dedicated to this project, SAGES can now offer surgeons posting in these groups the ability to discuss preoperative, intraoperative (even during live feed), and postoperative issues with other SAGES colleagues and mentors. In addition, the platform permits transparent and responsive dialogue about technique, continuing the theme of deliberate, lifelong learning.

To accommodate the needs of this program, SAGES University is upgrading its web-based features. A new learning management system (LMS) will track progression and make access to SAGES University simple. Features of the new IT infrastructure will provide the ability to access a video or lecture on demand in relation to content, level of difficulty, and author. Once enrolled in the MASTERS Program, the LMS will track lectures, educational products, MCE, and other completed requirements. Participants will be able to see where they stand in relation to module completion, and SAGES will alert learners to relevant content they may be interested in pursuing. Until such time that the new LMS is up and running, it is hoped that the SAGES Manual will help guide learners through the MASTERS Program Curriculum.

Conclusion

The SAGES MASTERS Program Colorectal Surgery Pathway facilitates deliberate, focused postgraduate teaching and learning. The MASTERS Program certifies completion of the curriculum but is not meant to certify competency, proficiency, or mastery of surgeons. The MASTERS Program embraces the concept of continued learning after fellowship, and its curriculum is organized from basic principles to more complex content. The MASTERS Program is an innovative, voluntary curriculum that supports MOC and deliberate, lifelong learning.

References

1.

Jones DB, Stefanidis D, Korndorffer JR, Dimick JB, Jacob BP, Schultz L, et al. SAGES University Masters Program: a structured curriculum for deliberate, lifelong learning. Surg Endoscopy. 2017;31(8):3061–71.Crossref

2.

Dreyfus SE. The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177–81.Crossref

3.

Graham R, Mancher M, Miller Woman D, Greenfield S, Steinberg E, Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we can trust. Washington, D.C.: National Academies Press (US); 2011.

4.

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–6.Crossref

5.

Greenberg CC, Ghousseini HN, Pavuluri Quamme SR, Beasley HL, Wiegmann DA. Surgical coaching for individual performance improvement. Ann Surg. 2015;261:32–4.Crossref

6.

Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282–3.Crossref

7.

Sachdeva AK. Acquiring skills in new procedures and technology: the challenge and the opportunity. Arch Surg. 2005;140:387–9.Crossref

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

P. Sylla et al. (eds.)The SAGES Manual of Colorectal Surgeryhttps://doi.org/10.1007/978-3-030-24812-3_2

2. Masters Program Colorectal Pathway: Laparoscopic Right Colectomy for Benign Disease

Tonia M. Young-Fadok¹  

(1)

Mayo Clinic College of Medicine, Division of Colon and Rectal Surgery, Phoenix, AZ, USA

Tonia M. Young-Fadok

Email: [e-mail]

Keywords

Right colectomyLateral-to-medialMedial-to-lateralAnastomosisExtracorporealIntracorporeal

Introduction and Rationale

Being able to perform mobilization, resection, and reestablishment of bowel continuity for right colectomy is an essential set of skills for all general surgeons who perform colon and rectal procedures [1].

In basic terms, laparoscopic colorectal surgery can be broken down into three anatomic building blocks: mobilization of the right colon; mobilization of the left/sigmoid colon; and mobilization with transection of the rectum. Completion of each of these blocks results in that segment of the colon or rectum becoming a mobile midline structure which can then be exteriorized through a periumbilical or other suitable incision.

Of these three essential building blocks, right colectomy is widely considered to be technically the easiest to learn, and the procedure has the best safety profile in terms of having the lowest anastomotic leak rate compared with either sigmoid resection or rectal resection. This chapter focuses on right colectomy for benign disease in order to establish basic principles. The presumption is that benign disease is easy for the novice laparoscopic surgeon and safe for the patient [2]. The provisos are that the two commonest indications (polyp and Crohn’s disease) are not complex examples of the cases for those early in the learning curve, i.e., that a right colon polyp is not clinically suspicious for a malignancy or that ileocolic Crohn’s disease is not associated with fistulas or a phlegmon. Much less common examples of benign right-sided disease include diverticular disease and cecal volvulus.

Indications and Contraindications

The commonest indication for right colon resection is neoplasia of the right colon, which includes right colon cancer and right-sided polyps. Resection of the right colon for known malignancy is covered in a separate chapter. Although polyps of the right colon that are too large to be resected endoscopically should also be considered to harbor a risk of cancer and an oncologic resection should be performed, polyps thought to be at low risk for harboring malignancy are generally felt to be a safe model for the novice laparoscopic surgeon.

The next commonest indication is ileocolic Crohn’s disease [3]. Early in the learning curve, it is wise to avoid complex Crohn’s disease with multiple fistulas or a tethered phlegmon, but simple ileocolic disease is an excellent model for early experience. Knowledge of how to mobilize the right colon and transect the mesentery is also necessary for more extensive colorectal procedures including total colectomy or proctocolectomy for indications such as Crohn’s colitis, ulcerative colitis, colonic polyposis syndromes, and colonic inertia.

Other general contraindications to a laparoscopic approach, not related to the specific procedure, also apply, such as marked colonic or small-bowel distention precluding attainment of an adequate pneumoperitoneum; levels of obesity that can also prevent an adequate working space; hemodynamic instability; and intestinal perforation with multiloculated pus or fecal peritonitis. A relative contraindication, dependent on the experience of the surgeon, is advanced tumor with involvement of adjacent organs requiring en bloc resection.

Principles and Quality Benchmarks

Whatever the indication for right colectomy, establishment of the landmarks is critical for a safe procedure. Mobilization of the right colon is the simplest of the three building blocks described above. It introduces skills such as recognition of the retroperitoneal plane and identification of the right ureter, inferior vena cava (IVC), and duodenum and incorporates decision-making regarding delineation of the vasculature and where it should be divided.

The primary distinction between resection for benign disease and resection for malignant disease is that oncologic principles are not in force. For right colon cancer, an oncologic operation requires specific margins of bowel resection, high ligation of the vascular pedicles, and an intact mesenteric envelope to ensure adequate lymph node harvest. In benign disease, e.g., Crohn’s ileocolitis, resection margins are determined by the extent of disease, and transection of the mesentery can be a division of convenience , i.e., dividing the colon where the division is most easily achieved without the potential additional dissection and exposure required for proximal ligation of vascular pedicles.

Another principle in oncologic resection is maintenance of an intact mesentery and standard extent of lymphadenectomy to meet current guidelines for lymph node harvest, and this is captured in the concept of complete mesocolic excision (CME) . During mobilization of the colon, this means in essence remaining in the correct embryologically defined anatomical plane that separates the retroperitoneum from the colon. This is a bloodless plane, and staying in this plane protects the ureter, inferior vena cava (IVC), and duodenum. It is therefore recommended to use this dissection plane also for benign disease, even though there is no oncologic necessity as in a cancer case.

There are no benchmarks specific to the performance of right colectomy for benign disease. However, resection margins for large polyps with a risk of cancer should be identical to a cancer operation. In Crohn’s disease the standard of care is to resect to macroscopically and palpably normal bowel.

Preoperative Planning, Patient Workup, and Optimization

As with all patients being considered for an operation, the diagnosis should be reviewed and confirmed. If necessary, further expert opinions should be sought regarding the need for resection, e.g., the role of an adjusted medication regimen in Crohn’s disease, or repeated colonoscopic evaluation of a large polyp if the Paris classification were not reported on the original procedure. The location of pathology should be confirmed as far as possible preoperatively, with tattooing, CT imaging, etc. to avoid the need for intraoperative colonoscopy unless the latter is considered part of the procedure (e.g., combined endoscopic resection/laparoscopic visualization of a polyp).

All patients undergoing elective resection of the colon should undergo a general workup to optimize their condition for an operation in addition to the appropriate workup for the specific disease entity. It is now standard of care that specific entities are addressed or corrected for preoperative patient optimization: anemia, poor blood sugar control, malnutrition, smoking, and excessive alcohol use. If time allows, consideration should also be given to preconditioning of the deconditioned patient. The reader is also referred to the relevant chapters on checklist for patients in preparation for laparoscopic colorectal surgery (Chap. 9) and enhanced recovery protocols in colorectal surgery (Chaps. 7 and 8) [4].

Operative Setup

Operating Room Setup

Careful placement of the video screens, insufflator, and light source is required to maximize access to the abdomen and minimize entanglement of cords (Fig. 2.1). The primary view screen is generally on the right side of the patient, with the subsidiary screen on the left. Some ORs will have ceiling-mounted booms that carry the equipment and make this planning simpler. In ORs with cart-mounted equipment, one must anticipate that the surgeon and camera assistant will both need to be on the left side of the patient, facing the right colon, and the bank of equipment needs to be able to move between the patient’s hip and shoulder in order to maintain the desirable straight line between the surgeon’s hands, operative site, and screen, as this helps to minimize surgeon fatigue.

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Fig. 2.1

Operating room setup

Patient Positioning

Steep position changes are often necessary to facilitate exposure and move small bowel out of the operative field, and it is imperative to prevent slipping. The patient is usually placed in the supine position, on egg crate foam secured to the OR table, or other mechanism to prevent the patient moving during steep position changes. A draw sheet is placed beneath the patient, and behind the foam to maximize patient contact with the foam, to then allow the sheet to be wrapped around the patient’s arms to align them alongside the patient after padding of the hands. Alternatively, a combined synchronous position with the patient in low stirrups can be considered to allow for the surgeon to be positioned between the legs to facilitate access during mobilization of the hepatic flexure. This is helpful when mobilization of the hepatic flexure is more complex than usual (phlegmon/large mass at the hepatic flexure, obesity) or if intraoperative endoscopy is anticipated. In this case, the patient’s thighs should be flat and aligned with the patient’s abdomen to prevent interference of the patient’s knees during the use of lower abdominal trocars. During the main portion of the case, both surgeon and assistant will need to be on the left side of the patient, facing the right colon. Preferably, both arms are tucked at the patient’s sides, or at least the left arm should be tucked alongside the patient.

Operative Technique: Surgical Steps

There are, quite simply, two approaches to the right colon. One either chooses lateral-to-medial [5] or medial-to-lateral. Multiple other approaches have been described including inferior upwards and top-down from the hepatic flexure. This does not change the fact that there are basically two approaches. The lateral-to-medial approach uses the right lateral peritoneal reflection as a marker for entering the correct retroperitoneal plane. The medial-to-lateral approach starts by isolating the base of the ileocolic pedicle and using this as an entry into the retroperitoneal plane.

This chapter will focus on the technique of extracorporeal creation of the anastomosis following resection. The techniques for intracorporeal anastomosis are covered in a separate chapter.

Trocar Placement

Insertion of trocars should be adapted to the case.

In the most simple cases, i.e., limited ileocolic resection in the patient with BMI <30, it is possible to fully mobilize the right colon and exteriorize it through a periumbilical incision, without needing to divide either the mesentery or the bowel intracorporeally. A triangular configuration, facing the right colon, uses umbilical, suprapubic, and left lower quadrant port sites.

In the event that the case is not simple, requiring an additional port either to divide the mesentery or to mobilize a phlegmon, an additional fourth trocar is placed (Fig. 2.2). This can be positioned in the right lower quadrant or the left upper quadrant, where an instrument through this port is generally deployed by the camera holder.

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Fig. 2.2

Trocar placement

Mobilization of the Right Colon

Lateral-to-Medial Dissection (Table 2.1)

The main aim of this approach is full mobilization of the right colon to the midline. This makes the right colon a midline structure and allows choices regarding ligation of the vasculature and transection of the mesentery [6].

Table 2.1

Steps for lateral-to-medial right colectomy

Classically in this approach, the patient is first placed in Trendelenburg position with the right side inclined up. The right lateral peritoneal reflection alongside the cecum and ascending colon is identified and scored. My preference is for an electrocautery device rather than a bipolar device which when used inappropriately can enter a nonanatomic plane. Once the correct retroperitoneal plane is identified, the cecum is gently swept medially, and the ureter is identified and protected (Fig. 2.3a, b). With the cecum under tension, which means retracting it medially and cephalad, the medial peritoneal reflection alongside the distal terminal ileum can be entered, and the terminal ileal mesentery can be mobilized off of the retroperitoneum.

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Fig. 2.3

(a) Cecum, and right ureter covered by peritoneum. (b) Cecum, and right ureter exposed after peritoneum incised

The right lateral peritoneum alongside the ascending colon is exposed by retracting the ascending colon towards the midline. The anterior surface of Gerota’s fascia should remain intact (Figs. 2.4 and 2.5). The dissection can be continued towards the liver (Fig. 2.6). In a patient with a BMI <30, the ascending colon can be mobilized to the midline, releasing its attachments from the duodenum and allowing visualization of the mesenteric window cephalad to the ileocolic pedicle (Fig. 2.7). In patients of higher BMI, this particular view may not be visible until the mobilization of the hepatic flexure is completed.

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Fig. 2.4

Gerota’s fascia inferior portion

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Fig. 2.5

Gerota’s fascia mid portion

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Fig. 2.6

Right lateral peritoneal reflection at hepatic flexure

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Fig. 2.7

Mesenteric window cephalad to the ileocolic pedicle

The operative table should then be placed in reverse Trendelenburg still with the OR table inclined right side up. The hepatocolic attachments at the hepatic flexure should be identified. These can be better delineated by gently lifting them up noting the movement of the superficial tissues over the underlying retroperitoneal plane. This will help to identify the plane of transection which can be developed between the retroperitoneal plane and the hepatocolic attachments (Fig. 2.8). These attachments often have small blood vessels, and here a vessel sealing device can be helpful (Fig. 2.9).

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Fig. 2.8

Developing the plane beneath the hepatocolic attachments

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Fig. 2.9

Division of hepatocolic attachments

It is helpful to determine the most medial desired point of mobilization of the transverse colon and start by elevating the hepatic colic attachments here. The plane can be entered and the hepatic colic attachments divided, working laterally towards the dissection which has already been done from the lateral aspect. During this dissection, the duodenum should be identified and protected (Fig. 2.10).

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Fig. 2.10

Duodenum at hepatic flexure

For a right colon cancer, at this point the base of the ileocolic pedicle and the right branch of the middle colic vessels can be clearly delineated, and the association of the latter with the pancreatic inferior margin can likewise be confirmed (Fig. 2.11) [6]. The right branch of the middle colic artery can be divided at this point, with the patient still in reverse Trendelenburg while viewing the hepatic flexure from above (Fig. 2.12).

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Fig. 2.11

Base of the middle colic artery and duodenum

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Fig. 2.12

Right branch of middle colic artery

The patient can then be placed in a neutral horizontal position while still maintaining the right side inclined upwards. The fat pad at the ileocolic pedicle is placed under tension and elevated after laying the colon back in its normal anatomic position, which allows visualization of the entire medial aspect of the mesentery. The remaining peritoneum of the mesenteric windows cephalad and caudad to the base of the ileocolic pedicle is scored, and the base of the ileocolic pedicle is isolated. After confirming the position of the duodenum through the cephalad window (Fig. 2.13), the ileocolic pedicle may be divided at the level of the lateral border of the duodenum. In benign disease, high ligation near the origin of the superior mesenteric vein (SMV) is not indicated.

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Fig. 2.13

Duodenum and pancreas seen through cephalad mesenteric window

Proponents of this approach indicate the ease of identifying the correct retroperitoneal plane and the ability to mobilize the right colon to the midline.

Medial-to-Lateral Dissection (Table 2.2)

The first step is putting the ileocolic pedicle under tension by grasping the fat pad on the medial aspect of the mesentery adjacent to the ileocecal junction (Fig. 2.14). This exposes the two mesenteric windows, one cephalad above the ileocolic pedicle and the other caudad and inferior to the ileocolic pedicle. In patients with BMI <30, the duodenum can be visualized through the cephalad mesenteric window, and a transverse line of dissection can be estimated across the base of the ileocolic pedicle, in line with the lateral margin of the duodenum (Fig. 2.15). In the heavier patient (BMI >30), the anatomy is often difficult to discern. After a transverse scoring incision is made across the medial peritoneum of the right colon, over the estimated base of the ileocolic pedicle; careful dissection is employed to achieve two aims: isolation of the base of the ileocolic pedicle and identification of the retroperitoneal plane by using gentle sweeping actions to elevate the posterior aspect of the mesentery off the retroperitoneum. Once the base of the ileocolic pedicle is identified, the vein and artery can be dissected separately and divided using an electrocautery device (Fig. 2.16). For benign disease, the artery and vein can often be divided together using an advanced energy or stapling device. Many surgeons also prefer the addition of an endoloop to confirm control of the vascular supply.

Table 2.2

Steps for medial-to-lateral right colectomy

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Fig. 2.14

Exposure of the medial aspect of the ascending colon mesentery and the base of the ileocolic pedicle

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Fig. 2.15

Duodenum seen after opening mesenteric window cephalad to the base of the ileocolic pedicle

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Fig. 2.16

Division of ileocolic artery

Dissection then continues in the correct retroperitoneal plane, sweeping the right ureter, IVC, gonadal vessel, and duodenum posteriorly while elevating the right colon and extending the plane of dissection to the right lateral peritoneal reflection. The mesenteric transection is carried towards the chosen proximal margin in the distal ileum and also towards the chosen distal resection margin in the colon. Full mobilization is extended laterally to the right lateral peritoneal reflection which is then also divided. As entry into this plane is somewhat by trial and error, without the landmark provided by the right lateral peritoneal reflection, videos of this approach tend to have a more bloody exposure, other than in expert hands. In patients with Crohn’s disease, division of the mesentery can be challenging due to marked thickening and also friability if steroids have been used. Transection of the mesentery may be safer near the base of the ileocolic pedicle where mesenteric thickening is less prominent, or the mesentery may be more safely approached extracorporeally after exteriorization of the mobilized right colon.

Proponents of this approach indicate early vascular control as an important feature. The lymph node harvest may be greater [7] although the oncologic significance of more than 12 lymph nodes is as yet unclear.

Top-Down Approach

This approach is a variant of the lateral-to-medial approach described above except that it starts at the hepatic flexure rather than at the cecum. This is slightly more technically challenging than starting at the cecum, as there is no peritoneal reflection. This is an attractive option when inflammation from ileocolic Crohn’s disease or a desmoplastic reaction from a cecal cancer obscures the retrocecal plane.

Transection and Anastomosis of the Right Colon

Decisions regarding transection margins, and intra- versus extracorporeal anastomosis, are often decided ahead of time based on the patient’s underlying diagnosis and pathology. It is important, however, to be able to adjust the operative approach as indicated by intraoperative findings. In the case of ileocolic Crohn’s disease, the distal transection margin is generally somewhere in the ascending colon, as determined by the extent of disease. Mobilization of the hepatic flexure is still helpful, not to obtain margins but in order to obtain adequate length to perform a long side-to-side anastomosis if that is the preferred method.

For the novice and intermediate surgeon, laparoscopic mobilization is the minimum necessary to make the distal ileum, right colon, and proximal transverse colon a mobile section of bowel that, in a patient of BMI <25–30, can be exteriorized through a periumbilical incision with the resection and anastomosis performed extracorporeally. Patients with a higher BMI should have the vascular pedicle and mesentery divided intracorporeally, and this allows the anastomosis to be performed extra- or intracorporeally without tension and pulling on the middle colic vessels. Intracorporeal anastomosis, addressed in a separate chapter, requires more advanced skills [8–10].

With regard to extraction incisions, the easiest incision to use is a periumbilical incision. This requires only mobilization of the right colon to the midline, at which point it is now a midline structure and can be easily exteriorized. However, this incision is associated with a higher subsequent incisional hernia rate [11]. Transection of the mesentery and vasculature intracorporeally allow additional choices in terms of an extraction incision, and a right lower quadrant or even a Pfannenstiel incision can be employed. Use of a wound protector may reduce the risk of surgical site infection. Transrectal extraction has been described for specific distal colonic and rectal procedures, but is not advocated for right-sided procedures and requires intracorporeal anastomosis .

Pitfalls and Troubleshooting

Troubleshooting is the forethought given to avoiding pitfalls! Difficulties can potentially be anticipated in certain settings: uncertain location of lesion, obesity, and inflammation.

A common error with both lateral and medial approaches is straying from the correct retroperitoneal plane, which can disrupt either the complete mesenteric excision plane by being too superficial or dissect too deeply into the retroperitoneum risking injury to the right ureter, inferior vena cava, or duodenum. With the lateral approach, being both too lateral and too deep can incur the risk of undermining the right kidney.

A bulky mass or extensive inflammation should prompt a very close look on CT scan at the relationship to the ureter, and consideration should be given to placement of ureteral stents to assist intraoperative identification of the ureter.

While T4 malignancies and large Crohn’s phlegmons can be approached laparoscopically by an experienced surgeon, these are not cases for the novice laparoscopic surgeon and should prompt conversion if they were not anticipated preoperatively. Other indications for conversion are inability to find the correct tissue planes, concern regarding injury to the ureter, IVC or duodenum, and uncontrolled bleeding. Failure to make progress with the procedure is also an indication to convert.

Learning curves are a popular way of conveying the potential difficulty of learning a procedure. For a straightforward right colectomy, in the absence of complex anatomy or pathology, a trainee who is capable of performing a laparoscopic cholecystectomy should be able to develop the skills for right colectomy, as described here with extracorporeal anastomosis, within 5–10 cases. More complex techniques, such as single-incision right colectomy [12], intracorporeal anastomosis, and complete mesorectal excision, have longer learning curves which are yet to be defined.

Outcomes

Most level 1 evidence for the role of laparoscopy in colorectal surgery has focused on randomized controlled trials (RCTs) for colon cancer and subsequently for rectal cancer. There is less evidence for benign disease. For example, a Cochrane review found only two RCTs for ileocolic Crohn’s disease, involving 120 patients, and concluded that there was no significant difference in perioperative outcomes and long-term reoperation rates for disease-related or non-disease-related complications of Crohn’s disease. Multiple cohort studies exist, however, that cumulatively support the benefits of a laparoscopic approach, to the point where RCTs became untenable from the perspective of assuming equipoise. In other words, repeated, consistent, believable evidence from reliable experts led to the situation whereby it would not be possible to devise a RCT where the investigator truly believed that it was unknown whether either arm of a laparoscopic vs open RCT would show improved outcomes.

Laparoscopic approaches gained acceptance with reported advantages of faster return to normal activity and diet, reduced hospital stay, reduced postoperative pain, and better cosmesis. Longer-term, laparoscopic surgery has shown smaller abdominal fascial wounds, lower incidence of hernias, and decreased rates of small bowel obstruction from adhesions (Table 2.3).

Table 2.3

Short and long term advantages of laparoscopy

Although evidence accumulated re. potential improved outcomes from laparoscopy, there also came concerns related to the loss of tactile evaluation of the bowel, i.e., missing occult segments of Crohn’s disease and inability to palpate a polyp which would not have visible serosal manifestations. These issues are usually addressed by the exhortation to define anatomy preoperatively, e.g., CT enterography to elicit evidence of proximal small bowel disease in Crohn’s, and use of tattooing, CT colonography, and intraoperative endoscopy to localize polyps.

Conclusions

Laparoscopic right colectomy for benign disease is a good starting point for those learning the skills necessary for minimally invasive colorectal surgery , including not just trainees but also surgeons already experienced in open colorectal procedures but wishing to develop laparoscopic skills. Operative planning, OR setup, patient positioning, and trocar placement are important components of a successful operation that also recognizes correct tissue planes, resection margins, anastomotic technique, and specimen retrieval.

References

1.

Champagne BJ, Steele SR, Hendren SK, Bakaki PM, Roberts PL, Delaney CP, et al. The American Society of Colon and Rectal Surgeons Assessment Tool for performance of laparoscopic colectomy. Dis Colon Rectum. 2017;60(7):738–44.

2.

Homma S, Kawamata F, Yoshida T, Ohno Y, Ichikawa N, Shibasaki S, et al. The balance between surgical resident education and patient safety in laparoscopic colorectal surgery: surgical resident’s performance has no negative impact. Surg Laparosc Endosc Percutan Tech. 2017;27(4):295–300.

3.

Dasari BVM, McKay D, Gardiner K. Laparoscopic versus open surgery for small bowel Crohn’s disease. Cochrane Database Syst Rev. 2011;(1):CD006956.

4.

Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg. 2019;43(3):659–95.

5.

Young-Fadok TM. Video podium presentation, SAGES Annual Meeting 2018. Session: masters colorectal: MIS approaches to the right colon. Laparoscopic lateral-to-medial dissection – a safer approach? [Internet]. Available from: https://​www.​youtube.​com/​watch?​v=​zAz_​XdSceh8

6.

Lee SJ, Park SC, Kim MJ, Sohn DK, Oh JH. Vascular anatomy in laparoscopic colectomy for right colon cancer. Dis Colon Rectum. 2016;59(8):718–24.

7.

Honaker M, Scouten S, Sacksner J, Ziegler M, Wasvary H. A medial to lateral approach offers a superior lymph node harvest for laparoscopic right colectomy. Int J Colorectal Disease. 2016;31(3):631–4.

8.

Biondi A, Santocchi P, Pennestri F, Santullo F, D’Ugo D, Persiani R. Totally laparoscopic right colectomy versus laparoscopically assisted right colectomy: a propensity score analysis. Surg Endosc. 2017;31(12):5275–82.

9.

Martinek L, You K, Giuratrabocchetta S, Gachabayov M, Lee K, Bergamaschi R. Does laparoscopic intracorporeal ileocolic anastomosis decreases surgical site infection rate? A propensity score-matched cohort study. Intl J Colorectal Dis. 2018;33(3):291–8.

10.

Milone M, Elmore U, Di Salvo E, Delrio P, Bucci L, Ferulano GP, et al. Intracorporeal versus extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided colorectal cancers. Surg Endosc. 2015;29(8):2314–20.

11.

Pares D, Shamali A, Stefan S, Flashman K, O’Leary D, Conti J, et al. Predictive factors for extraction site hernia after laparoscopic right colectomy. Int J Colorectal Disease. 2016;31(7):1323–8.

12.

Haas EM, Nieto J, Ragupathi M, Aminian A, Patel CB. Critical appraisal of learning curve for single incision laparoscopic right colectomy. Surg Endosc. 2013;27(12):4499–503.

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

P. Sylla et al. (eds.)The SAGES Manual of Colorectal Surgeryhttps://doi.org/10.1007/978-3-030-24812-3_3

3. Masters Program Colorectal Pathway: Laparoscopic Left and Sigmoid Colectomy for Benign Disease

Julia T. Saraidaridis¹   and Peter W. Marcello¹  

(1)

Lahey Hospital and Medical Center, Division of Colon and Rectal Surgery, Burlington, MA, USA

Julia T. Saraidaridis (Corresponding author)

Email: [e-mail]

Peter W. Marcello

Email: [e-mail]

Keywords

Laparoscopic sigmoid colectomyLaparoscopic left colectomyHand-assisted laparoscopyDiverticulitis

Introduction and Rationale

Laparoscopic colectomy was first described in the early 1990s. The first randomized trials evaluating laparoscopic colectomy versus open surgery were in patients with malignant disease. These trials demonstrated less blood loss, earlier recovery of bowel function, less need for narcotics, and a shorter length of stay for patients who had procedures performed laparoscopically [1–5]. Because of the inflammatory nature of most benign conditions prompting colectomy, there was some hesitation regarding the feasibility of a laparoscopic approach for these indications. Slowly, data evaluating laparoscopic sigmoid colectomy in patients with diverticulitis accumulated [6–10]. These studies demonstrated that laparoscopic left or sigmoid colectomy is possible in patients with diverticular disease with an increased operative time compared to open surgery, a decreased length of stay, and a decreased complication profile. They also demonstrated that conversion is less for surgeons who utilized a hand-assisted laparoscopic approach . Using these two approaches, straight laparoscopy and hand-assisted laparoscopy, most patients with diverticular disease requiring sigmoid colectomy can undergo surgery in a minimally invasive fashion. This chapter details the indications, operative technique, and outcomes of studies evaluating laparoscopic and hand-assisted laparoscopic (HAL) sigmoid and left colectomy for benign disease.

Indications and Contraindications

The most common benign condition that prompts left or sigmoid colectomy is the many manifestations of diverticulitis including recurrent disease, smoldering disease, colovesical/colovaginal fistula, or stricture. Other benign conditions prompting an elective left or sigmoid colectomy include Crohn’s colitis, ischemic colitis, endometriosis, or diverticular bleeding. As diverticulitis is the most commonly seen disorder requiring left or sigmoid colectomy in benign disease, this chapter will focus on this indication.

In the past, the inflammation and scarring associated with the chronic manifestations of diverticular disease prompted many surgeons to shy away from minimally invasive approaches. However, increasing experience with both hand-assisted laparoscopy and straight laparoscopy has prompted minimally invasive techniques to be the mainstay of treating this condition. In our practice, for repeated attacks of uncomplicated diverticulitis, we proceed with a straight laparoscopic approach with a planned extraction through a small Pfannenstiel incision. For patients with a body mass index greater than 30 kg/m², the size of the extraction site for a straight laparoscopic case is relatively similar to a hand-assisted incision. So, for this reason, for morbidly obese patients, we utilize a hand-assisted approach. Additionally, for any patient with a history of complicated diverticulitis including abscess, phlegmon, or fistula, a hand-assisted laparoscopic approach can be particularly helpful to facilitate blunt dissection and identify the correct surgical planes.

There are very few contraindications to approaching benign conditions of the left and sigmoid colon using a laparoscopic approach. Contraindications include patients who are unable to tolerate laparoscopy or steep changes in operating room table positioning. A relative contraindication is the presence of dense or extensive adhesions associated with a prior history of open laparotomy in the past. With experience, however, most laparoscopic surgeons will attempt a laparoscopic approach, even in the setting of previous open surgery. Extreme caution should be taken when entering the reoperative abdomen in order to avoid an injury, especially in the setting of prior peritonitis, prior intraabdominal bleeding, or previous mesh placement, which may result in formation of dense adhesions. If the abdomen proves to be hostile, conversion to an open procedure should quickly be decided.

Principles and Quality Benchmarks of the Approach/Technique

The principles of resection for diverticular disease are the same in laparoscopic approaches as they are in open approaches: isolation and ligation of the sigmoid pedicle, mobilization of the left and sigmoid colon including takedown of the splenic flexure, proximal transection, distal transection at the proximal rectum, and anastomosis. For diverticular disease , there are additional parameters including the performance of an adequate colon resection to minimize recurrence of disease and an attempt to decrease the risk of common complications of sigmoid resection. In our practice, to assist in reducing the risk of recurrence of diverticular disease, all prior CT scans are evaluated to assess the proximal extent of disease. Any portion of the bowel that has been involved in previous inflammation/diverticulitis attacks is included in the planned resection. Once in the operating room, prior to initiating the mobilization of the bowel, the bowel is palpated to assess for chronic thickening or acute inflammation. The proximal transection margin does not need to be so proximal so as to include all diverticula, it just needs to be proximal enough to include all areas of previous inflammation. It should also be on soft, pliable bowel with soft pliable mesentery. The planned proximal colon transection can be marked (using an ink pen tip, clip, or cautery) at the start of the operation. This will ensure that the appropriate proximal margin is achieved which can be more challenging to determine once the colon and its mesentery are fully mobilized. The distal transection margin should be on the proximal rectum. This is identified by the splaying of the taeniae (Fig. 3.1a, b). A colorectal rather than a colosigmoid anastomosis is believed to be the single most important factor in decreasing the chance of recurrent diverticular disease [11, 12].

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Fig. 3.1

(a, b) Splaying of the taeniae

In addition to providing an adequate resection, a principle of left/sigmoid resection for benign disease is to avoid a high ligation of the sigmoid pedicle. The avoidance of a high ligation decreases the risk of ureteral injury and hypogastric nerve injury. Some studies have indicated that avoiding a high ligation of the pedicle decreases the chance of anastomotic leak [13]. Other studies have not confirmed this association [14]. However, in our practice for benign disease, we preserve the sigmoid pedicle given this concern.

Preoperative Planning, Patient Work-Up, and Optimization

In the planning of a minimally invasive approach to surgical resection for diverticulitis, a number of factors must be considered preoperatively. For those patients whom have not had a colonoscopy in the 2 years prior to resection, repeat endoscopic evaluation is warranted. Some of our surgeons will perform an on-table colonoscopy on the day of surgery in order to avoid repeating a bowel preparation. For patients with complicated diverticulitis, additional factors must be taken into account preoperatively. Patients with residual diverticular abscess and/or fistula will keep their percutaneous drain up until the time of surgery. The drain will be prepped into the field and then removed once the abdomen has been entered. For those patients with suspected colovesical fistula, cystoscopy and ureteral stent placement are usually performed just prior to surgery. If the fistula takedown results in a bladder defect, it should be repaired with sutures. In regard to ureteral stent usage in the absence of colovesical fistula, the decision to place stents prophylactically is up to the individual surgeon. In general, when significant inflammation and/or residual phlegmon, abscess, or fistula is anticipated, left-sided stents are usually placed prophylactically to minimize the risk of an unrecognized ureteral injury.

All prior abdominal scars should be evaluated as potential extraction sites. Patients are educated about enhanced recovery pathways including non-opioid pain relief alternatives, early ambulation, and early resumption of diet. All of our patients undergoing elective colon surgery undergo mechanical and antibiotic bowel preparation the day before surgery. Please refer to the chapters on enhanced recovery protocol in colorectal surgery for more details on this topic (Chaps. 7 and 8).

Operative Setup

Patients are placed on a bean bag in a modified lithotomy position on a split-leg table. The arms are tucked at the sides and surrounded by foam padding and an inflated bean bag. The chest is wrapped circumferentially three times with three-inch silk tape affixing them to the table. The legs are split with the buttock at the bottom of the table to allow for trans-anal access, and then the legs are secured in place with Velcro straps. Patients are given subcutaneous heparin, and sequential compression devices are applied for deep venous thrombosis prophylaxis. Antibiotics are administered less than 1 hour prior to surgical incision. We use both monopolar cautery and the bipolar vessel sealer as our energy sources. Both of these instruments are placed on the field at the initiation of the case. A CO2 colonoscope is available as needed for the procedure. Most cases are initiated with a colonoscopic evaluation of the colon. The Foley catheter is placed after colonoscopy in women to avoid risk of urinary tract infection as our group found that there was contamination of the catheter from colonoscopy if it had been placed pre-procedure. The catheter is draped over the leg to reduce contamination from the passage of staplers and endoscopes trans-anally.

Operative Technique

Port Placement

For straight laparoscopic procedures, a 12 mm Hassan port is placed in the umbilicus. 5 mm ports are placed in the right upper quadrant, the right lower quadrant, and the left lower quadrant (Fig. 3.2). Extraction is most often performed through a small Pfannenstiel incision or via an extension of the Hassan port site.

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Fig. 3.2

Room setup for laparoscopic sigmoid colectomy . (Used with permission of Springer Nature from Leroy et al. [26])

For a hand-assisted approach, the operation begins with the creation of an incision for the hand-port. Early along the learning curve of hand-assisted, an 8 cm lower midline incision is recommended in the case that conversion is required. Once the surgeon is comfortable with a hand-assisted approach, a Pfannenstiel incision 2 cm above the pubis is the preferred approach. The incision is cosmetically pleasing, has an extremely low risk of incisional hernia, and is an excellent incision to work in the pelvis where further dissection or an anastomosis can be completed. The hand device is placed into the incision, and then three 5 mm trocars are placed in the left lateral, right lateral, and umbilical positions (Fig. 3.3). The trocars are placed with the hand inside the abdomen to protect the intestines from injury. Following access to the abdomen, the procedural steps of the operation are performed in the same sequence whether the procedure is performed by straight laparoscopic or a hand-assisted laparoscopic approach .

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Fig. 3.3

Room setup for HAL sigmoid colectomy . (Used with permission of Springer Nature from Sonoda [25])

Left/Sigmoid Colectomy

The surgeon and assistant stand on the patient’s right side. The patient is placed in a mild Trendelenburg and left-side up position. In our practice, we perform a medial to lateral mobilization of the left/sigmoid colon. To do this, the omentum is lifted over the transverse colon, and the small bowel is moved out of the pelvis to the right upper quadrant (Fig. 3.4). The bare area of the left colon (the mesentery just lateral to the IMV between the left colic and first sigmoidal branches) is grasped and lifted. This mesentery is incised just lateral to the IMV, and a dissection begins between the left colon mesentery and Gerota’s fascia. The gonadal vessels will be below with Gerota’s fascia, and the dissection continues out to the lateral side wall. The left ureter is typically under the IMA pedicle and will not be seen unless dissection is carried backwards toward the aorta. The first one or two sigmoid branches are then identified, isolated, and divided with the bipolar vessel sealer. The left colon is then mobilized from medial to lateral in a plane overlying Gerota’s fascia (Fig. 3.5). This dissection extends out to the left pelvic sidewall, inferiorly into the upper retrorectal space, and superiorly up towards the splenic flexure.

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Fig. 3.4

The omentum is lifted over the transverse colon and the small bowel is moved to the right side of the abdomen. (Used with permission of Springer Nature from Leroy et al. [26])

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Fig. 3.5

Medial to lateral mobilization . (Used with permission of Springer Nature from Leroy et al. [26])

After the medial to lateral mobilization has been performed, the lateral attachments starting with the white line of Toldt are divided (Fig. 3.6). This maneuver connects the medial dissection plane to the lateral dissection plane. Moving up towards the splenic flexure, the lateral aspects of the splenic flexure are divided. For this part of the procedure, the assistant moves to the area between the legs and holds the camera with his left hand and the hook cautery with his right hand through the left-sided trocar. In this same position, the omentum is taken off of the distal transverse colon allowing the splenic flexure to be approached from a medial direction. Then the distal transverse mesocolon is freed from the inferior boarder of the pancreas. At this point, the colon should be assessed for reach down to the proximal rectum. If the reach is adequate, the mesentery can be taken with a bipolar device up to but not crossing the marginal artery on the proximal transection margin (the rest of the mesentery will be ligated once the colon is exteriorized). For the distal transection margin, the mesentery can be taken up to the edge of colon laparoscopically. However, if the procedure is being performed with a hand-assisted, that portion of the case can be done via the hand-port in an open fashion. At that point, the bowel can be exteriorized (Fig. 3.7), and the specimen can be brought out through the hand-port (in the case of hand-assisted) or through an extraction site (straight laparoscopy). In the situation of straight laparoscopy, a small wound protector should be used to ease specimen extraction and to protect the wound from contamination.

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Fig. 3.6

Taking down the lateral attachments. (Used with permission of Springer Nature from Sonoda [25])

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Fig. 3.7

Exteriorizing the sigmoid colon. (Used with permission of Springer Nature from Leroy et al. [26])

The proximal transection and distal transection are completed via the extraction site. For straight laparoscopy, the anvil is placed in the proximal colon which is returned to the abdomen. The stapled colorectal anastomosis can be performed while under laparoscopic view (or in some cases through the wound directly if a Pfannenstiel or lower midline incision is used). It is critical to ensure that there are no twists in the proximal colon or the mesentery and that the small bowel is not trapped under the left colon mesentery before the stapler is fired. For hand-assisted cases the anastomosis can be performed through the hand-port site. The anvil is secured to the stapler and closed under direct visualization. However, prior to firing of the stapler, a pneumoperitoneum is reestablished to ensure that the proximal colon and its mesentery are not twisted, that the small bowel is not trapped under the left colon mesentery, and that there is no tension upon the anastomosis. In either approach, the omentum is brought down over the small bowel and colon to an anatomical position. Following the anastomosis, air leak testing is performed with CO2 colonoscopy, and the mucosa is examined for perfusion. The anastomosis may be reinforced with a few additional